Individual & Family Enrollment Application

All plans require selection of a Primary Care Physician (PCP). Click here to find a doctor.

Date enrollment should become effective

Please select an effective date from the available options.

During the annual Open Enrollment period, which runs from November 1, 2017 through January 31, 2018, you may apply for coverage, or members can change plans.

If BlueCross BlueShield receives the enrollment application on or before December 15, 2017, coverage will begin on January 1, 2018, as long as the applicable premium payment is received by then.

If BlueCross BlueShield receives the enrollment application between the dates of December 16, 2017 through January 15, 2018, coverage will begin February 1, 2018, as long as the applicable premium payment is received by then.

If BlueCross BlueShield receives the enrollment application between the dates of January 16, 2018 through January 31, 2018, coverage will begin March 1, 2018, as long as the applicable premium payment is received by then.

If you do not enroll during open enrollment, or during a special enrollment period, you must wait until the next annual open enrollment period to enroll.

During the annual Open Enrollment period, which runs from November 1, 2018 through January 31, 2019, you may apply for coverage, or members can change plans.

If BlueCross BlueShield receives the enrollment application on or before December 15, 2018, coverage will begin on January 1, 2019, as long as the applicable premium payment is received by then.

If BlueCross BlueShield receives the enrollment application between the dates of December 16, 2018 through January 15, 2019 coverage will begin February 1, 2019, as long as the applicable premium payment is received by then.

If BlueCross BlueShield receives the enrollment application between the dates of January 16, 2019 through January 31, 2019, coverage will begin March 1, 2019, as long as the applicable premium payment is received by then.

If you do not enroll during open enrollment, or during a special enrollment period, you must wait until the next annual open enrollment period to enroll.

Select a 2019 medical plan

Bronze Standard
#

Bronze Ind align

Bronze Ind focus

Silver Standard
#

Silver Ind align

Silver Ind focus

Gold Standard
#

Gold Ind align

Gold Ind focus

Platinum Standard
#

Platinum Ind align

Platinum Ind focus

No medical plan

Select 2019 dental plan (if applicable)

Blue Pediatric Dental
&

Blue Value Dental 1
&

Blue Value Dental 2
&

Blue Value Dental 3
&

No dental plan

Note: If you have multiple children and would like to provide each
of them with pediatric dental coverage, then you will have to complete a separate
version of this application for each child.

Select a 2020 medical plan

Bronze Standard
#

Bronze Ind align

Bronze Ind focus

Silver Standard
#

Silver Ind align

Silver Ind focus

Gold Standard
#

Gold Ind align

Gold Ind focus

Platinum Standard
#

Platinum Ind align

Platinum Ind focus

No medical plan

Select 2020 dental plan (if applicable)

Blue Pediatric Dental
&

Blue Value Dental 1
&

Blue Value Dental 2
&

Blue Value Dental 3
&

No dental plan

Note: If you have multiple children and would like to provide each of them with
pediatric dental coverage, then you will have to complete a separate version of this application
for each child.

* - Required field

# - Plan can be purchased as child-only coverage

& - Meets pediatric dental essential health benefit requirement

Child Only

The selected coverage is available as child only coverage.
Do you want to continue enrolling using the child only version of this plan?

Enroll as Child Only Coverage?

Yes

No

Note: If you have multiple children and would like to provide
each of them with a child only plan, then you will have to complete a separate version of this
application for each child.

Reason for Enrollment/Change

Reason

New Coverage

Open Enrollment

Change Policy

Remove Dependent

Add Dependent(s) to Current Coverage

Loss of Coverage

Address / Phone Number

Primary Care Physician (PCP)

Last Name

Date of qualifying event

Payment options

Payment period

Monthly

Quarterly

Responsible Person Information

Last Name

First Name

M.I.

Mailing Address

Apt or Suite

City

State

Zip

Subscriber Information

Last Name

First Name

M.I.

Social Security Number

Date of Birth

Telephone Number

Email Address

Gender

Male

Female

Marital Status

Single

Married

Divorced

Legally Separated

Widowed

Domestic Partner

Marital Status Event Date

Subscriber Address

Mailing Address

Apt or Suite

City

State

Zip

County

Primary Care Physician

Primary Care Physician's Last Name

Primary Care Physician's First Name

Primary Care Physician Number

Is this member a current patient? If not a current patient, have they verified that the PCP will
accept them as a new patient?

Yes

No

Additional Questions

Has this member obtained
stand-alone dental coverage for children under the age of 19 that
provides a pediatric dental essential health benefit through a
New York State of Health, the Official Health Plan Marketplace
(NYSOH)-certified stand-alone dental plan offered outside the NYSOH?

Yes

No

If you answered "no", we will provide coverage of the pediatric dental essential health benefit. Additional
premium will apply.

Add Spouse/Domestic Partner

Do you have a spouse or a domestic partner to add to this plan?

Yes

No

Spouse/Domestic Partner Information

Last Name

First Name

M.I.

Social Security Number

Date of Birth

Email Address

Gender

Male

Female

Primary Care Physician

Primary Care Physician's Last Name

Primary Care Physician's First Name

Primary Care Physician Number

Is this member a current patient? If not a current patient, have they verified that the PCP will
accept them as a new patient?

Yes

No

Add Dependent

Do you have other dependents you would like to add to this plan?

Yes

No

How many other dependents do you have?

Would you like to add coverage for dependents up to age 30?

Yes

No

Notice!

Click on any of the text headings below to open a section that contains a form that you can fill out for each of your dependents.

Is this member a current patient? If not a current patient, have they verified that the PCP will
accept them as a new patient?

Yes

No

Enrollment Verification

Are you completing this enrollment form:

Individually

With a Broker or Sales Rep

Agent/Broker Certification

To be completed by your BlueCross BlueShield of Western New York appointed agent/broker:

Did you see the proposed applicant and spouse/domestic partner,
if applying at the time this application was executed?

Yes

No

Please explain why you didn't see the applicant:

Last Name

First Name

M.I.

Address

Include your street address, suite no., and personal mailbox (PMB) no. if available

City

State

Zip

Phone number

Fax number

Email

Individual Producer ID

Agent / Broker Signature

I CERTIFY TO THE BEST OF MY KNOWLEDGE AND BELIEF, THE RESPONSES HEREIN ARE ACCURATE.

I agree, and it is my intent, to sign this form and submit my application by writing my name on the form and by electronically submitting this application. I understand that my signing and submitting this application is the legal equivalent of having placed my hand written signature on the application. I understand and agree that by electronically signing this application in this way, I am affirming to the truth of the information contained in this application.

I agree

Signature

Use your mouse to sign your full name below to complete enrollment.

Subscriber Signature

I AUTHORIZE ANY LICENSED DOCTOR, HOSPITAL OR OTHER HEALTH CARE PROVIDER TO PROVIDE MY PLAN WITH ANY INFORMATION OR DOCUMENTS REQUESTED CONCERNING MEDICAL SERVICES I OR MEMBERS OF MY FAMILY HAVE RECEIVED, WHICH THE PLAN DETERMINES IS NECESSARY FOR THE OPERATION AND REGULATION OF THE PLAN. THIS INFORMATION WILL BE KEPT CONFIDENTIAL AND IS VALID FOR UP TO 24 MONTHS. * ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

I agree, and it is my intent, to sign this form and submit my application by writing my name on the form and by electronically submitting this application. I understand that my signing and submitting this application is the legal equivalent of having placed my hand written signature on the application. I understand and agree that by electronically signing this application in this way, I am affirming to the truth of the information contained in this application.

I agree

Signature

Use your mouse to sign your full name below to complete enrollment.

Review

Please review your online enrollment application information before submitting. If you find any
issues, you can close this dialog and navigate back to the step the issue is
on and fix it there.

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Individual & Family Enrollment Application Overview

Thank you for choosing BlueCross BlueShield of Western New York.

Before you begin please have the following information for each applicant:

Social Security Number

Date of Birth

We can help you find out if you qualify for a subsidy to help pay for your health plan. Contact one of our benefit consultants at 1-800-888-5407 for more information.

If you are enrolling a dependent and are choosing the age 29 rider, an additional form must be submitted before the enrollment can be completed. Please contact Customer Service at 1-855-344-3425 to have the form mailed to you, or a form will be mailed once we receive your application.